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The diagnosis and management of menopause to empower patients

Updated: Jul 20, 2023

Menopause can be a challenging time. Symptoms arise in 80-90% of patients, with 25% describing symptoms as severely debilitating…



Over the last few years, the menopausal landscape has massively shifted across the UK. Clinicians are now seeing more patients with menopausal-related issues than ever before. One of the key contributing factors was the groundbreaking documentary released by Davina McCall in 2021. The 60-minute documentary saw the presenter candidly open up about her shame surrounding early menopause and HRT. In doing so she bravely created an empowering shift, inspiring a wave of women to seek appointments and treatment.


This has been dubbed ‘The Davina Effect’ with NHS figures showing HRT requests skyrocketing in 2021, by an extra 500,000

As clinicians, you play a pivotal role in optimising these transitional years, proving both a backbone of knowledgeable support and treatment. Confidently being able to discuss the latest guidelines and treatment options is key. We have summarised both NICE guidelines and the most up-to-date government changes to provide guidance on treatment options and to clarify the most common misconceptions surrounding menopause.



Individualist approach

Menopause is a transitional phase in a woman's life and should be approached with the utmost empathy and consideration. All patients are unique both in their response to oestrogen deficiency and subsequent treatment.


For this reason, there is not a ‘one-size-fits-all’ treatment plan, each patient requires extensive assessment on an individual basis.

This means considering the patient's current and past symptoms, family history, individual preferences and concerns, diet and lifestyle. Advice should be given holistically with a particular focus on the cessation of smoking, weight loss, alcohol reduction, exercise importance, mindfulness techniques (CBT) and general well-being.




Treatment

Vasomotor symptoms (flushes & sweats)

HRT is considered the most effective treatment strategy with minimal risks to those suffering with symptoms such as hot flushes and sweats. Many different factors influence the type of HRT chosen such as family history, medication, perimenopausal or postmenopausal, if the patient has had a hysterectomy etc.


Low mood

For patients that are demonstrating symptoms of low mood due to menopause, HRT should be considered rather than clonidine or antidepressants. CBT has also been clinically proven to help ease symptoms and is a natural alternative to HRT.


Low sexual desire

For patients with a low amount of sexual desire testosterone can be considered if HRT with adequate oestrogen is not effective however, the use of testosterone is off-license.


Urogenital atrophy

A hugely under-recognised and under-treated symptom of low oestrogen is both vaginal and bladder-related problems. It is recommended via NICE guidelines that vaginal oestrogen is offered, it can be used long-term with minimal risks due to the low absorption rate around the body. For some patients suffering from urogenital atrophy, vaginal oestrogen is recommended alongside HRT. For those patients suffering from vaginal dryness or irritation, over-the-counter moisturizers have been shown to provide relief and restore moisture to the vagina. Water-based lubricants are also recommended to women suffering from dryness during penetrative sexual activity.



Treatment Risks

The short-term and long-term benefits and risks should be discussed in detail. Each patient should be treated on an individualist basis in relation to their symptoms, improving their quality of life and both cardiovascular and bone benefits.


Breast cancer

Combined HRT is associated with a small increase in the risk of breast cancer, while oestrogen alone HRT is associated with little or no change. Despite this, the risks should be weighed up in the context of the overall benefits of using HRT.


Risk of VTE

Transdermal HRT does not increase VTE risk therefore, this type of HRT should be considered in women with a risk of VTE and includes women with an increased BMI.


Risk of heart disease

Oral HRT has not been found to significantly increase the risk of heart disease when started before the age of 60. In fact, research demonstrates that HRT may provide a protective function against coronary artery disease, helping to control cholesterol levels and overall HRT reduce the risk of a heart attack.


Risk of stroke

Oral HRT is associated with a small increase in the risk of stroke. For women under the age of 60 generally, the risk of stroke is low hence, the overall risk of a HRT-associated stroke is relatively small.


Treatment Benefits

HRT can help to relieve and alleviate menopausal symptoms, such as:

  • Vaginal dryness

  • Mood swings

  • Night sweats

  • Bladder issues

  • Hot flushes

  • Reduced sex drive

  • Brain fog

  • Anxiety

  • Skin and tissue quality

  • Joint and muscle aches and pain


HRT can also help protect a woman's body against:

  • Osteoporosis- HRT replaces the oestrogen in a women's body helping to maintain healthy bones.

  • Cardiovascular disease- as mentioned above HRT helps to control cholesterol levels overall reducing the risk of cardiovascular disease.



Provision of Information

It is your duty as a clinician to inform patients of the stages and symptoms of menopause and perimenopause extending beyond typically associated symptoms. While for many women HRT provides more benefits than risks it is still important to fully explain the risks associated. Taking the time to clearly explain the side effects of different treatment options and what generally to expect goes a long way to ease and comfort the patient. Coupling a thorough explanation with informatics and further informational points of reference is important, especially with newly diagnosed and perimenopausal patients. There is a whole plethora of websites, leaflets, and magazines the patient can access. Furthermore, many surgeries have the option of sending templated SMS messages directly to a patient's phone, this can be a great tool for sending relevant links.


Here are some highly recommended resources for patients:

Diagnostic blood tests

Over the age of 45years

Patients aged 45 and over, demonstrating indicative symptoms of perimenopause should be considered based on symptoms alone without confirmatory blood tests. In the past measuring FSH has been a key diagnostic tool in the confirmation of both perimenopause and menopause. Recent guidance has now changed indicating that FSH levels fluctuate significantly bearing no correlation with the severity of the symptoms or the induction of treatment. Reducing the need for FSH testing reduces the delay in commencing agreed management.



Under the age of 40years

For those patients under the age of 40, presenting symptoms suggestive of Premature Ovarian Insufficiency (POI), it is important that two confirmatory FSH blood tests are taken 4-6weeks apart for accurate diagnosis. Once POI is confirmed the advised treatment plan consists of HRT and the combined pill. Treatment should continue until the patient is of a natural age for the induction of menopause (at least 51 years).



Accessibility & Cost

As clinicians, it is important to be aware of the social factors surrounding both the accessibility and cost of treatment for women. The Davina Effect has significantly increased the demand for HRT and unfortunately has been attributed to HRT national shortages. Women have been desperately turning to the black market, seeking treatment abroad and spending thousands on HRT.


In response to this, a new national scheme is set to start from April 1st 2023. Women will have access to a year worth of treatment for only £18.70; saving up to £205 annually

The idea behind the prescription pre-payment certificate (PPC) is that patients can use an unlimited number of HRT items across a 12-month span. This includes tablets, topical treatments and patches, helping women discover the correct treatment plan for them without financial barriers.


In addition to reducing costs, the government is working towards boosting supply issues surrounding HRT. The announcement of PPC is a hugely positive first step towards addressing the challenges and inequalities faced by those requiring access to menopausal care.



Review & Referral

When to review?

If a patient commences HRT there should be a review scheduled three months prior, as this allows the patient to settle into the treatment. Thereafter the patient should be reviewed annually. Previously held views of HRT treatment duration were that it should be stopped after 2-5 years or at the age of 60 years however, these claims have not been backed scientifically. Thereby, since every patient is unique there are no arbitrary limits for the duration of treatment since we the duration of symptoms cannot be predicted.



When to refer?

Referral to a specialist menopausal service should be considered if:

  • There is uncertainty about the correct treatment option for the patient's symptoms

  • Menopausal symptoms do not improve with various treatments

  • Ongoing side effects with treatment that are troublesome

  • Patients who have contraindications to HRT


Further resources for clinicians:

If you would like further information in terms of the most up-to-date guidance, check out the resources below:


If you would like a refresher HRT consultation check out our membership page.




Sources:




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